PART II: THE OR

On the cutting edge: Dr. Justin Routhier scrubs up and takes part in surgical procedures

Halfway through his surgical training at Signature Healthcare Brockton Hospital, Dr. Justin Routhier had operated on a dozen people. But he doesn’t count the surgeries by the number of people. He counts them in body parts.

By Jessica Scarpati, Enterprise staff writer

   That was not Jerry Dunn of Whitman on the operating table. It was his gallbladder.
   At least that was the way Dr. Justin Routhier saw his third surgery of the day.
   Halfway through his month-long surgical training at Signature Healthcare Brockton Hospital, the resident had assisted as surgeons operated on a dozen people. But he doesn’t count the surgeries that way. He counts them in body parts.
   “I did two appendix — what’s the plural of appendix? Appendices? Two of those this morning before breakfast,” Routhier said through his surgical mask, referring to the appendectomies in which he assisted staff surgeon Dr. Julie White.
   He furiously scrubbed his hands and arms moments before he would help White again, this time to remove the gallbladder inside Dunn, 64. It was Routhier’s 50th surgery, he thinks, going back to his days as a medical student at Brown University — but he has stopped counting.

House-hunting while in the middle of surgical rotation takes its toll

By Jessica Scarpati, Enterprise staff writer
   Halfway through gallbladder removal surgery, a cell phone rang.
   “That’s my phone,” said Dr. Justin Routhier sheepishly, unable to press a button to silence it — his hands full of laparoscopic surgical equipment plunged into a patient’s belly.
   “Is that the Realtor?” asked the attending surgeon, Dr. Julie White.
   He hoped so.
   Routhier and his wife, renting in Stoughton for the beginning of his first-year residency at Signature Healthcare Brockton Hospital, had been house-hunting.
   They married a few weeks ago before he began his residency, returning from a honeymoon in Indonesia the day before he began work.
   Like most newlyweds, they were eager to build their life together in a place they could call their own.
   There was a single-family home in the Roslindale neighborhood of Boston they had put an offer on two days prior.
   “We were supposed to hear back some time today, maybe tomorrow,” he said after the surgery.
   If calling the process of buying a home “stressful” is an understatement, there may be no word for trying to do it while completing a surgical rotation.
   “Last weekend, I had two days (off) and we spend them seeing houses,” Routhier said.
   “I come home at 8’o’clock and I eat dinner and I’m kind of not in a good mood, but we have to talk about our budget, offers and houses,” he said.
   “It’s more of talking on the phone during the day when I get a free minute,” Routhier added. “My wife is obviously doing a lot of the groundwork, which is very helpful because I can’t really do anything when I get home.”
   He looked away.
   “So, yeah, it’s pretty hard actually. I wouldn’t recommend it,” he said.
   A week passed. The offer was accepted. He didn’t want to jinx it.
   “(We) still have to talk about purchase and sales, et cetera, so still not set in stone yet,” Routhier said.
   The first weekend of September, they moved in. The made sure not to be living out of boxes for a while, noting, “We have a bureau.”
   With so little time, how did they pull it off?
   “The Internet,” Routhier said.
   “You’re probably thinking it would be an emotional experience for me, but it’s not really anymore,” he said.
   Surgery has no room for emotional attachment, he explained.
   “What helps with, obviously, recognizing the patient as a person is meeting and greeting the patient before the operation, hearing their story, talking a little bit, joking around,” Routhier said.
   He did just that with Jerry Dunn and his wife, Dianne, in the pre-operating room.
   But being “semi-detached,” as he put it, is part of life in surgery.
   “When you’re in the OR and the drapes are over the patient’s head, and you know the focal point is just the abdomen or whatever body part’s being operated on, it’s very easy to block the rest out,” Routhier said.
   Routhier plans to complete his medical training at Brigham and Women’s Hospital, and wants to become a radiologist. But the yearlong residency at Signature requires doctors to get firsthand experience of other specialties — including surgery.
   “It really opens their eyes to an entire class of patients and cases,” said Dr. David Drinkwater, chief of surgery at the hospital.
   “They’re ultimately going to be the consultants for the surgeons, so they’ll be in their shoes,” added Dr. Dale Ellenberg, their medical education director at Signature.
   Med students generally assist in the “basics” of surgery — incisions, suturing and caring for a surgical patient — in their third year of medical school, said Ellenberg, so they have experience in the OR. How much they do during their residency depends on the surgeon they are assisting.
   This gallbladder removal was expected to take an hour — “nothing” for Routhier, compared to some surgeries he assisted in while a student.
   “I’ve been on a couple cases, like gastric bypass surgeries, that have lasted a long time, and you can’t complain,” he said, shrugging as he recalled hunching over for 10 hours during one surgery.
   But that wouldn’t be the case today. If gastric bypass were the three-course meal of surgical procedures, gallbladder removal, it seemed, would be the drive-through window.

A surgical solution
   Dunn’s gallbladder had to be removed because a pebble-size ball of bile, or gallstone, had formed inside, then caused an infection when it left the organ and blocked the duct leading to the pancreas.
   Dunn had passed the gallstone, but doctors feared the potentially dangerous situation could repeat itself.
   The procedure would be done laparoscopically, using a technique that relies on inserting cameras and instruments into small incisions in the abdomen, instead of cutting open the body.

ENDOSCOPY

   What is it? A general term for procedures, surgical or diagnostic, done with the insertion of an illuminated camera and other instruments through a small incision or natural body cavity.
   Examples
   Arthroscopy — interior of joints
   Colonoscopy — colon
   Gastroscopy — gullet, stomach, duodendum
   Laparoscopy — abdomen or pelvis
   At Signature Healthcare Brockton Hospital:
   Endoscopic procedures have increased 25 percent from 2005 to 2008.
   They accounted for about 40 percent of all general surgery cases over that same time period.
   Hernia: about 60 percent of cases are done laparoscopically.
   Appendectomies: about 75 percent of are done laparoscopically.
   Bowel: about 70 percent of cases are done laparoscopically.
   Gallbladder: almost all cases are done laparoscopically.
   Gynecological surgery: Most of it is done laparoscopically, as well as knee scopes.
   Endoscopy — the general term used for any minimally invasive procedure done with cameras — is “much harder” than traditional surgery, Routhier later said.
   “Things are lopsided, and you have to concentrate on the surgeon’s focal point the entire time,” he said. “You have to anticipate where they’re moving to next.”
   A patient with frequent “gallbladder attacks” is recommend to have the organ removed to prevent future inflammations, according to the National Institutes of Health. It is a nonessential organ.

Inside the OR
   It was 1:32 p.m., each passing second punctuated by another beep of the heart monitor.
   There is no music in Dr. Julie White’s operating room. Yellow walls. Hushed voices. Few jokes. Plenty of pleases and thank-you’s.
   An anesthesiologist stood at the patient’s head. Routhier and White flanked each side of Dunn.
   A nurse stood near White, nestled between two cascading trays of surgical equipment — one extending over the patient’s feet.
   The room was not large, but not cramped — despite the abundance of computers and machines that lined the perimeter, many of which remained untouched throughout the procedure.
   Routhier and White connected the equipment to two televisions that would project the scene.
   Once Dunn was anesthetized, Routhier pulled the skin taut with tweezers so White could make the first incision — about the diameter of a quarter — for a long rod-like instrument called a trocar, which had a camera attached.
   “He’s got a scar here you want to try to avoid,” White quietly instructed Routhier before settling on an incision site.
   A machine hummed in the back of the room. The patient’s belly inflated with carbon dioxide — “So we can see inside,” Routhier later explained.
   Within minutes, four foot-long poles jutted from the man’s abdomen.
   Routhier was mostly motionless — any movement could affect the surgeon or harm the patient — not so much as wiping sweat off his forehead or shifting his weight.
   White went to work, snipping and sizzling fat off the gallbladder so it could be peeled off the liver, to which it is attached.
   The surgeon and resident gazed over each other’s shoulders into twin TV screens — Routhier darting the camera around to trail White’s maneuvers.
   White would sometimes announce her next move, but it was often up to Routhier to anticipate it.
   After securing the gallbladder in a small, fishing net-like bag inside the belly — “Play basketball, doctor?” White asked Routhier — it was removed.

Wrapping up
   They released the air from Dunn’s belly, which rippled like a waterbed.
   Nurses wheeled Dunn into the post-op room — a smiling Routhier was there to greet him when he came to.
   It was just halfway through this rotation, but the 4:30 a.m. wake-up was wearing on him.
   “I don’t have much time at home,” Routhier said later. “It kind of stinks, but it’s just one month and I just have to get through it.”
   Today was just another gallbladder — out in an hour. No sweat.
   The paperwork that follows — that would be the hard part.

Dr. James Knutson wears his striking red and green sneakers when he is on call. He says they help staff tell him apart from another intern who is also tall and shaves his head. (Tim Correira/The Enterprise)
By Jessica Scarpati, Enterprise staff writer
   What’s red and green and comes charging toward you when you’re having a heart attack?
   Dr. James Knutson.
   On your next nighttime trip to the emergency room, look out for the scarlet Nikes with the lime green swish. That’s how you know Knutson is on call.
   “These are my old running shoes, so they’ve been relegated to the on-call footwear,” he said. “They’ve been getting rave reviews in the hospital.”
   His kicks also help colleagues tell him apart from Dr. Nathan Himes, who is also tall and bald.
   “For a while they were confusing Nate and I because we like to wear similar hairstyles,” Knutson said. “I finally had to tell people — you look for the red shoes, and that’s how you know it’s James.”
By Jessica Scarpati, Enterprise staff writer
   When Dr. Dale Ellenberg isn’t drumming medical knowledge into the eight first-year residents he supervises, he’s banging on snares and cymbals as “Dr. Dale” with The Downtown Players.
   The blues rock band plays in area restaurants and pubs, jamming to original tunes and covering everyone from James Brown to Santana.
   Check them out online at myspace.com/downtownplayers and downtownplayers.net.
   Catch Dr. Dale and the Players at 9 p.m. Oct. 4 at Huckleberry’s Chicken House in Middleboro, and Oct. 18 at Christopher’s Seafood & Steak in Raynham.
Dr. James Knutson checks his pager while on his rounds. (Tim Correira/The Enterprise)
Video and text by Tim Correira, Enterprise staff writer
   BROCKTON — Dr. James Knutson had his on-call pager off for a month and it was glorious.
   Life took a turn — somewhat — toward normalcy in September as he completed his radiology rotation, an elective, at Tufts Medical Center in Boston.
   The more flexible schedule was good timing for him and his wife, Katherine, who had “a few household emergencies” in their South Boston condo.
   “My dishwasher started leaking,” Knutson said. “If I had been in surgery, it would have been weeks before I could use the dishwasher and be home long enough to have the plumber come out and fix it.”
   But even better, he has been studying the specialty he hopes to pursue as a career — radiology.
   “Many of the procedures have been fun, but there are some boring ones,” he acknowledged, noting he tried to pick cases that interested him most.
   “I also have had a lot of time to catch up on some of the monumental amount of reading that I have to do as part of the program,” Knutson added.
   He returned each Tuesday to Signature Healthcare Brockton Hospital to work in the hospital’s clinics, practicing outpatient care, mostly for the uninsured and underinsured.
   As the rotation wound down, Knutson started to get that itch again.
   “I'm ready to get my edge back,” he said, heading down a dimly lit corridor of the hospital’s fourth floor.
   “I’m almost ready for anything,” Knutson added, on his way to the clinic. “We'll see what happens tonight.”